Important note Even though this policy may indicate that a particular service or supply may be considered covered, this conclusion is not based upon the terms of your particular benefit plan. Each benefit plan contains its own specific provisions for coverage and exclusions. Not all benefits that are determined to be medically necessary will be covered benefits under the terms of your benefit plan. You need to consult the Evidence of Coverage to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between this policy and your plan of benefits, the provisions of your benefits plan will govern. However, applicable state mandates will take precedence with respect to fully insured plans and self-funded non- ERISA (e.g., government, school boards, church) plans. Unless otherwise specifically excluded, Federal mandates will apply to all plans. With respect to Senior Care members, this policy will apply unless Medicare policies extend coverage beyond this Medical Policy & Criteria Statement. Senior Care policies will only apply to benefits paid for under Medicare rules, and not to any other health benefit plan benefits. CMS's Coverage Issues Manual can be found on the CMS website. SERVICE: PRIOR AUTHORIZATION: Required. NOT required for Senior Care members. POLICY: Coverage for neuropsychological and psychological testing for the evaluation of a behavioral health diagnosis is subject to the specific terms and limitations of the benefit plan. Services for, or in connection with, an injury or illness arising out of, or in the course of, any employment for wage or profit, or that are court-ordered without documentation of medical necessity, are specifically excluded under many benefit plans. Services that are considered primarily educational or training in nature or related to improving academic or work performance are specifically excluded. Scott & White Health Plan may consider psychological testing as medically necessary when all InterQual criteria are met and when needed to enhance psychiatric or psychotherapeutic treatment outcomes after a detailed diagnostic evaluation if: 1) Testing is needed to aid in the differential diagnosis of behavioral or psychiatric conditions when the member's history and symptomatology are not readily attributable to a particular psychiatric diagnosis and the questions to be answered by testing could not be resolved by a psychiatric/diagnostic interview, observation in therapy, or an assessment for level of care at a mental health or substance abuse facility; or 2) Testing is needed to develop treatment recommendations after the member has been tried on various medications and/or psychotherapy, has not progressed in treatment, and continues to be symptomatic. Psychological testing is generally NOT considered medically necessary for pre-surgical clearance except in certain circumstances (See SWHP medical coverage policy # 137 Psychologic Evaluation for Medical Procedures.) Psychological testing is generally NOT considered necessary for uncomplicated cases of attention deficit disorder with/without hyperactivity (ADHD). Psychological testing beyond standardized parent interviews and direct, structured behavioral observation is generally NOT considered medically necessary for the diagnosis of pervasive Page 1 of 7
developmental disorders. (See SWHP medical coverage policy # 206 Autism Spectrum Disorders) Psychological testing is considered NOT medically necessary if the member is actively abusing substances, is having acute withdrawal symptoms, or has recently entered recovery, because test results may be invalid. Scott & White Health Plan may consider neuropsychological testing as medically necessary for hours not to exceed the InterQual limit, when InterQual criteria are met. InterQual criteria for neuropsychological testing are available for Acute brain insult and Other neurologic conditions (brain tumor in remission, dementia, epilepsy with cognitive impairment and multiple sclerosis with cognitive impairment). In addition Scott & White Health Plan covers neuropsychological testing as medically necessary when there has been EITHER: 1) a significant recent mental status change, which is not due to a metabolic disease or disorder, which has not responded to appropriate treatment; OR 2) a significant recent behavioral change, memory loss, or organic brain injury AND any one of the following Traumatic brain injury Stroke Brain tumor Cerebral anoxic or hypoxic episode Central nervous system (CNS infection Neoplasm or vascular injury of the CNS Neurodegenerative disorder Demyelinating disease Extrapyramidal disease Exposure to intrathecal agents known to be associated with cerebral dysfunction or cranial irradiation Difficulty distinguishing the neurocognitive effects of a neurogenic syndrome or dementia and a Major Depressive Disorder when appropriate treatment for the Major Depressive Disorder has not resulted in improvement in neurocognitive function Scott & White Health Plan does NOT cover neuropsychological testing for ANY of the following because it is considered experimental, investigational, or unproven for these indications (this list may not be all-inclusive): Autism Spectrum disorder (ASD) Pervasive Developmental Disorder (PDD) Chronic Fatigue Syndrome Chronic Pain Syndromes Page 2 of 7
Scott & White Health Plan does NOT cover Neuropsychological testing for ANY of the following because such testing is considered primarily educational in nature and not medically necessary (this list may not be all inclusive): Attention deficit disorder/hyperactivity disorder Baseline assessment in the absence of condition demonstrating medical necessity (e.g. athletes pre-injury) Developmental disability, developmental delay Learning disability Mental retardation or borderline intellectual function Screening evaluations or IQ testing Tourette s syndrome Other developmental disorders Educational testing or when performed primarily for educational purposes or for vocational testing, training, or counseling Services for or in connection with an injury or illness arising out of, or in the course of, any employment for wage or profits are specifically excluded under many benefit plans. Therefore, treatment for metal toxicity that occurs as a result of occupational exposure is generally not covered. OVERVIEW: Psychological tests assess a range of mental abilities and attributes, including achievement and ability, personality, and neurological functioning. Psychological testing, including neuropsychological assessment, utilizes a set of standardized tests, whose validity and reliability have been established empirically. They allow for an assessment of a patient's cognitive and behavioral functioning and an analysis of changes related to mental or physical disease, injury, or abnormal development of the brain. Research has shown that the scores from these tests are reproducible and can be compared to those of normal persons of similar age, sex and demographic background to yield valid conclusions. Psychological and neuropsychological tests provide a standardized means of sampling behavior, an objective method for evaluating responses, and a tool for comparing the functioning of an individual with peers. Standardized tests are administered under uniform conditions, scored objectively -- the procedures for scoring the test are specified in detail -- and designed to measure relative performance. Test results usually are interpreted with reference to a comparable group of people, the standardization, or normative sample. Psychological testing requires a clinically-trained examiner. All psychological tests should be administered, scored, and interpreted by a qualified professional, such as a licensed psychologist or psychiatrist, with expertise in the appropriate area. Psychological tests are only one element of a psychological assessment. They should never be used as the sole basis for a diagnosis. A detailed clinical interview, including a complete history of the test subject and a review of psychological, medical, educational, and other relevant records is required to lay the groundwork for interpreting the results of any psychological measurement. Page 3 of 7
Psychological tests are used to address a variety of questions about people s functioning, diagnostic classification, co-morbidity, and choice of treatment approach. For example, personality tests and inventories evaluate the thoughts, emotions, attitudes, and behavioral traits that contribute to an individual s interpersonal functioning. The results of these tests determine an individual's personality strengths and weaknesses, and may identify certain disturbances in personality, or psychopathology. One type of personality test is the projective personality assessment, which asks a subject to interpret some ambiguous stimuli, such as a series of inkblots. The subject's responses can provide insight into his or her thought processes and personality traits. Neuropsychological testing is a subclassification of psychological testing and consists of the administration of a series of standardized assessments designed to objectively measure cognitive function. This testing provides the basis for the conclusions regarding the neurocognitive effects of various medical disorders and aids in diagnosis. Neuropsychological testing is also used to assist in the differentiation of psychiatric from neurological disorders. Making an assessment of preserved and compromised cognitive functions can also help to predict the effects of remediation. Neuropsychological testing is indicated when notable behavioral and/or cognitive changes have been associated with a history of severe head trauma or organic brain disease. The testing results assist the clinician determine the scope and severity of cognitive impairments through a comparison of patient responses to established normative test values. This comparison then assists the clinician in developing a program or plan of care that is specific to the patient s needs. Neuropsychological testing should be delayed until reversible medical or metabolic conditions that are adversely affecting the central nervous system (CNS) are corrected, when possible. Formal neuropsychological testing should also be delayed until any acute changes have stabilized following trauma, infections, or metabolic or vascular insults to the CNS. Neuropsychological testing should only be performed or supervised by a psychologist who is both trained and experienced at neuropsychological testing, and is properly licensed in the State of Texas. Neuropsychological testing is used to assess cognitive function and to quantify the neurocognitive effects of various medical disorders and/or head trauma-related conditions. Neuropsychological testing is a tool to assist in the diagnosis of certain conditions, such as dementia, but is not a diagnostic tool in itself. Neuropsychological testing may sometimes be used to guide medical treatment or monitor response to treatment for subsequent re-examinations. MANDATES: There are no mandated benefits or regulatory requirements for SWHP to provide coverage for these services. CODES: Important note: CODES: Due to the wide range of applicable diagnosis codes and potential changes to codes, an inclusive list may not be presented, but the following codes may apply. Inclusion of a code in this section does not guarantee that it will be reimbursed, and patient must meet the criteria set forth in the policy language. CPT Codes: 96116, 96118, 96119, 96120 CPT Not Covered: ICD9 codes: 191.0-191.9 Page 4 of 7
192.0-192.9 198.3, 225.0, 237.5, 239.6 320.0-320.9 332.0-332.1 333.90, 340, 341.8, 341.9, 348.1, 348.31, 348.9, 434.01, 434.11, 434.91, 780.93, 799.0 854.0-854.1 984.0-984.9 997.02 ICD9 Not covered: 299.00-299.91, 307.23, 314.00-314.01, 315.00, 315.9, 317, 318.0-318.2, 319, 780.71, V80.0 ICD10 codes: C70.0-C71.9 - brain neoplasm C72.0-C72.9 - CNS neoplasm including cranial nerves D42.0-D43.9 - CNS neoplasm G00.0-G10 - infection and inflammation of CNS and Huntington s G20-G23.9 - Parkinson s and degenerative diseases of brain G30.0-G32.9 - dementia & degenerative diseases of brain G35-G37.9 - demyelinating disease of CNS i60.00-i68.8 - cerebrovascular diseases and disorders /CVA i69.01, i69.11, i69.21, i69.31, i69.81, i69.91 - cognitive deficits after CVA I97.810-I97.821 - intra-op CVA R41.1-R41.9 - amnesia and cognitive defects S06.1x0-S06.9x9 - intracranial injury ICD10 Not covered: F70-F79 - intellectual difficulties F80.1-F98.9 - developmental & emotional disorders, ASD R53.81-R83.83 - fatigue & malaise Z13.850 - encounter for screening for traumatic brain injury CMS: LCD L32766, Psychiatric Codes. POLICY HISTORY: Status Date Action New 8/1/2010 New policy Reviewed 12/28/2010 Reviewed. Reviewed 12/6/2011 Reviewed. Reviewed 2/21/2012 Reviewed. Reviewed 2/14/2013 Reviewed. Corrected 5/9/2013 Removed prior authorization requirement for Senior Care Reviewed 2/14/2014 Reviewed. ICD10 codes added. Reviewed 2/12/2015 Significant revisions REFERENCES: The following scientific references were utilized in the formulation of this medical policy. SWHP will continue to review clinical evidence surrounding neuropsychological testing and may modify this policy at a later date based upon the evolution of the published clinical evidence. Should additional scientific studies become available and Page 5 of 7
they are not included in the list, please forward the reference(s) to SWHP so the information can be reviewed by the Medical Coverage Policy Committee (MCPC) and the Quality Improvement Committee (QIC) to determine if a modification of the policy is in order. 1. American Academy of Clinical Neuropsychology. American Academy of Clinical Neuropsychology (AACN) practice guidelines for neuropsychological assessment and consultation. Clin Neuropsychol. 2007 Mar;21(2):209-31. 2. American Psychiatric Association. Practice guideline for the Psychiatric Evaluation of Adults. Second Edition. June 2006. Available at URL address: http://www.psychiatryonline.com/pracguide/pracguidetopic_1.aspx 3. American Psychiatric Association. Position statement: Recognition and Management of HIV-Related Neuropsychiatric Findings and Associated Impairments. October 2003. Available at URL address: http://www.psych.org/departments/edu/library/apaofficialdocumentsandrelated/positionstatements/ 200305.aspx 4. American Psychological Association, Presidential Task Force on the Assessment of Age-Consistent Memory Decline and Dementia (1998). Guidelines for the evaluation of dementia and age-related cognitive decline. Washington, DC: American Psychological Association. Available at URL address: http://www.apa.org/practice/dementia.html 5. Bagheri MM, Kerbeshian J, Burd L. Recognition and management of Tourette's syndrome and tic disorders. Am Fam Physician. 1999 Apr 1 5;59(8):2263-72, 2274. 6. Banks ME. The role of neuropsychological testing and evaluation: when to refer. Adolesc Med. 2002 Oct; 1 3(3):643-62. 7. Butcher JN, Perry JN, Atlis MM. Validity and utility of computer-based test interpretation. Psychol Assess. 2000 Mar;12(1):6-18. 8. Costa DI, Azambuja LS, Portuguez MW, Costa JC. Neuropsychological assessment in children. J Pediatr. 2004;80(2 suppl):s1 11-S116. 9. EAST Practice Management Guidelines Work Group. Practice management guidelines for the management of mild traumatic brain injury. Winston-Salem (NC): Eastern Association for the Surgery of Trauma (EAST); 2000. Available at URL address: http://www.east.org/tpg/tbi.pdf 10. Filipek PA, Accardo PJ, Ashwal S, Baranek GT, Cook EH Jr, Dawson G, et al. Practice parameter: screening and diagnosis of autism: report of the Quality Standards Subcommittee of the American Academy of Neurology and the Child Neurology Society. Neurology. 2000 Aug 22;55(4):468-79. 11. Jankovic J. Movement disorders. In: Goetz CG. Textbook of Clinical Neurology, 3rd ed. Philadelphia: Saunders, an Imprint of Elsevier; 2007. ch 34. 12. Kaplan HI, Sadock BJ, Sadock VA. Kaplan & Sadock s comprehensive textbook of psychiatry. Diagnosis and Psychiatry: Examination of the Psychiatric Patient. Part 7. Philadelphia: Lippincott Williams; 2005. 13. Luciana M. Practitioner review: computerized assessment of neuropsychological function in children: clinical and research applications of the Cambridge Neuropsychological Testing Automated Battery (CANTAB). J Child Psychol Psychiatry. 2003 Jul;44(5):649-63. 14. Patel DR, Shivdasani V, Baker RJ. Management of sport-related concussion in young athletes. Sports Med. 2005;35(8):671-84. 15. Petersen RC, Stevens JC, Ganguli M, Tangalos EG, Cummings JL, DeKosky ST. Practice parameter: early detection of dementia: mild cognitive impairment (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2001 May 8;56(9):1 133-42. 16. Pliszka S; AACAP Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry. 2007 Jul;46(7):894-921. 17. Schlegel RE, Gilliland K. Development and quality assurance of computer-based assessment batteries. Arch Clin Neuropsychol. 2007 Feb;22 Suppl 1:S49-61. Epub 2006 Nov 7. Page 6 of 7
18. Scottish Intercollegiate Guidelines Network (SIGN). Management of patients with dementia. A national clinical guideline. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network (SIGN); 2006 Feb. 19. Schatz P, Browndyke J. Applications of computer-based neuropsychological assessment. J Head Trauma Rehabil. 2002 Oct;17(5):395-410. 20. Stebbins GT. Neuropsychological testing. In: Goetz C. Textbook of clinical neurology. 3rd ed. Chicago, IL: W.B. Saunders Company; 2007. ch 27. 21. Tuchman R. Autism. Neurol Clin. 2003 Nov;21(4):915-32. 22. Volkmar F, Cook EH Jr, Pomeroy J, Realmuto G, Tanguay P. Practice parameters for the assessment and treatment of children, adolescents, and adults with autism and other pervasive developmental disorders. American Academy of Child and Adolescent Psychiatry Working Group on Quality Issues. J Am Acad Child Adolesc Psychiatry. 1999 Dec;38(12 Suppl):32S-54S. 23. Wild K, Howieson D, Webbe F, Seelye A, Kaye J. Status of computerized cognitive testing in aging: a systematic review. Alzheimers Dement. 2008 Nov;4(6):428-37. 24. Professional Societies/Organizations:American Academy of Neurology (AAN): The Quality Standards Subcommittee of the AAN published an evidence-based review: Practice parameter: early detection of dementia: mild cognitive impairment. The recommendations include (Petersen, et al., 2001): Page 7 of 7